Vermont - Medicaid Enterprise Update - June 2026

 

 

Greetings from the Green Mountain State!   Our lead researcher has been providing these updates for years, and we continue to encourage other State Medicaid Agencies (SMAs) and vendors to join in.  This outreach is a great way to maximize time at MESC, set expectations for the week, strengthen relationships, and gain valuable insights. Thank you for reading, and we wish you all a fantastic summer and look forward to seeing you in Portland, Oregon.

Status of Vermont’s Medicaid Enterprise Modernization

In collaboration with the Centers for Medicare and Medicaid Services (CMS), we continue to make progress in transforming our Medicaid Enterprise. We are proud to have five CMS-certified modules:

·        Care Management: Acentra Health

·        Provider Management Module (PMM): Gainwell Technologies

·        Health Information Exchange (HIE): Vermont Information Technology Leaders (VITL)

·        Electronic Visit Verification (EVV): Gainwell Technologies

·        Pharmacy Benefit Management (PBM): Optum

Vermont continues to follow the strategic plans we made with CMS starting with ‘getting our data in order”, remaining compliant with mandates, and proceeding in a fashion that meets Vermont’s needs.  We’re more than welcome to discuss the whole heap of our accomplishments before, during or after MESC vittles are served. 

  Below are some updates of our other key modernization activities underway :

·        Vermont’s Medicaid Data Warehouse and Analytics Solution (MDWAS) (Deloitte) is live, and CMS Certification Review is scheduled in August.  Vermont continues to reap many benefits of having claims, clinical and other Medicaid related data in a singular solution and establishment of a longitudinal record  

·        Vermont has many vendors that support our Enterprise Modernization work including:

o   Independent Verification and Validation (IV&V) via CSG Government Solutions

o   Procurement support by BerryDunn including their tHHS State Health Dashboard (SHD) to support CMS’ Operational Reporting Workbooks (ORW), Medicaid Information Technology Architecture (MITA), Status reports, and Advanced Planning Documents (APD).

o   CorrecTek and Gainwell for implementation activities to support CMS Department of Corrections Justice Re-entry requirements

o   Deloitte on implementation of Noticing Solution replacement and aforementioned MDWAS work

o   Gainwell Technologies to meet the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

·        Procurement notes:  

o   Vermont’s Integrated Eligibility System (VT-IES) is an active procurement, and we will provide an announcement once a contract has been executed. 

o   Our NASPO Pharmacy Benefits Solution procurement is an active procurement, and we will provide an announcement once a contract has been executed.

o   Vermont’s Agency of Human Services (AHS) has begun releasing Request for Proposals (RFPs) and Notice of Funding Opportunities (NOFOs) associated with our Rural Health Transformation (RHT) Program.  Active NOFOs and RFPs can be found on this webpage: RHT Program RFPs/NOFOs. 

o   Vermont’s Medicaid Enterprise Solution (MES) – formerly referred to as the Core Claims and Fiscal Agent Services. The MES title provides a more holistic view of this procurement.

§  We anticipate this Request for Proposals (RFP) to be released by the end of the summer.  This solution will not only address the many variations of claims processing and fiscal agent services but will also take advantage of our unified data to meet various workflow/case management and tracking needs, care management features, and administrative savings opportunities. 

§  Vermont will be seeking a proven Medicaid claims Design, Development, & Implementation (DDI) vendor.   The potential partner must own a software/technology solution that was either:  a) Designed, Developed and Implemented by their organization; or b) acquired and integrated into their core product(s) by the proposing organization; and in either case their solution must be CMS Certified and implemented by that vendor. Operating and maintaining a solution developed by another contractor does not meet this qualification. (Example:  takeover scenarios.) 

Expectations and plans for MESC 2026

Building on last year's conference and our ongoing modernization efforts, not to mention our continued interest in collaborating with other SMA, Vermont staff will continue our practice of visiting every booth to learn about vendors, their recent accomplishments, and upcoming projects.  We look forward to the continued building of relationships as we are all part of the HHS family…and for some in attendance, you are literally family!

 

SMA and Vendors:  Vermont staff are more than happy to set aside specific time at MESC for intimate and focused discussions.  If we are unable to find accommodating times in Portland, we can certainly set up something virtually after MESC.   Vermont is finalizing the list of Vermont attendees for MESC 2026 and we will share at a future time.   We've included a series of questions at the end of this update to help frame conversations.

 

Overview of Vermont’s Medicaid Program

 

Vermont Medicaid operates a publicly operated PIHP (Prepaid Inpatient Health Plan) delivery model through its 1115 demonstration waiver. It is not a traditional Managed Care Organization (MCO), Accountable Care Organization (ACO), or a full Fee-for-Service program.   For further information, refer to our annual report.

Quick Vermont Stats:

 

 

Be well and have a wonderful summer.

Thank you,

Joe

 

Send your responses to the following questions to Joseph.Liscinsky@vermont.gov by Friday, June 19. 

 

Questions for Vendors

Questions:

1.     How do you organize the work associated with an implementation of the size and scope of Medicaid Enterprise Solution? 

2.     What are the top 2 activities you wish SMA would accomplish or have in place prior to you kicking off your implementation work?

 

Questions for SMA

Questions:

1.     If you have had a Core Claims implementation in the past 5 years, would you be willing to:

·        Share your implementation timeline and any associated staffing plans

·        Share your base MMIS Core Claims contract with the Vermont team

            2. If you could go back and change 1 or 2 things about your original base contract, what would they be?

DVHA announces Medicaid Enterprise consulting and procurement assistance contract

The Department of Vermont Health Access is excited to announce that a contract was executed with Berry, Dunn, McNeil & Parker, LLC to provide Medicaid Enterprise consulting and procurement assistance.  The State of Vermont will leverage BerryDunn's) experience and expertise, and their Transform Health and Human Services (tHHS) product to support Enterprise Modernization efforts across the Medicaid Management Information System (MMIS), Integrated Eligibility & Enrollment (IE&E), and Health Information Technology/Exchange (HIT/HIE) Programs.  

Vermont - IE&E Modernization Update

 

IE&E Modernization Update     VT-IES Project Update Vermont submitted the VT-IES RFP to CMS/FNS for review on September 15. VT-IES will consist of a Customer Portal, Case Management, and a Rules Engine, replacing legacy enrollment systems and optimizing eligibility, enrollment, and customer management functionality. Vermont expects vendors to propose an implementation approach that delivers timely and incremental release of improvements. Vermont has updated its list of mandated technologies it expects a vendor's solution to integrate with to support end-to-end integration.   Find Out More: VT-IES Project   Noticing Project Update Vermont released an RFP in June 2023 to solicit bids to integrate with Hyland's Content Composer as the foundational noticing solution for the IE&E Program.  Vermont recognizes that alternate vendor solutions should be considered. Vermont has decided not to award a contract based on the June 2023 RFP. Vermont will open a new competitive procurement that does not mandate a preferred noticing technology and simplifies the desired integration approach. The future noticing solution will have an integration with VT-IES.   Vermont IE&E was at ISM! Vermont's IE&E Program had 17 staff from the Agency of Humans Services and the Agency of Digital Services attend the ISM Conference in Kissimmee last month. We appreciate your support of this event. Vermont's IE&E Program Director was invited to present to the Human Services IT Advisory Group (www.hsitag.org). This presentation is available on YouTube; please click www.youtube.com/watch?v=PnuE0QUtEtY&t=691s   You can learn more about our IE&E Program by visiting  Integrated Eligibility and Enrollment (IE&E) System | Agency of Human Services (vermont.gov).   Join our Mailing List for MMIS & IE&E Updates

Vermont posts two RFP - Analytics Data Warehouse (ADW) and Security as a Service (SECaaS)

The State of Vermont is excited to announce the posting of two RFPs

• RFP Medicaid Analytics Data Warehouse Solution
• RFP Security as a Service (SECaaS) Vendor

Be sure to tell your friends and family.   

Thanks. 

Vermont's 2023 - Pre-MESC Update

 

We’re only days away from the 2023 Medicaid Enterprise System Conference (MESC) and we know you’ve been anxiously awaiting Vermont’s annual pre-conference communication.   This allows us to maximize the opportunities at MESC, to further build relationships, gain additional information, and increase awareness about industry standards, best practices, and lessons learned. 

 

Vermont continues to move forward with transforming its Medicaid Enterprise and serving Vermonters in the most time efficient, secure and integrated manner.  Vermont has five Centers for Medicare and Medicaid Services (CMS) Certified modules:  Health Information Exchange (HIE) (Vermont Information Technology Leaders (VITL)), Electronic Visit Verification (EVV) (Gainwell & Sandata), Pharmacy Benefit Management (PBM), (Change Healthcare), Care Management module (Acentra Health (formerly Kepro (formerly eQHealth))), and Provider Management Module (PMM) (Gainwell Technologies).  Vermont is leveraging the expertise of our Independent Verification and Validation (IV&V) vendor (CSG Government Solutions) as we continue our Medicaid Enterprise transformation. 

Regarding Vermont’s Enterprise:

v  Medicaid Management Information System (MMIS) Program:  

o   Note-1:  Medicaid Data Lake and Analytic Solution (MDLAS) procurement was awarded to Deloitte and executed in July 2023.

o   Note-2:  Vermont will be releasing a Request for Proposals (RFP) for an Analytics Data Warehouse (ADW) to be implemented and will integrate with our MDLAS.  Be advised the ADW will be maintained by Vermont’s HIE. 

o   Note-3:  Vermont Medicaid is not a traditional Managed Care Organization (MCO), a traditional Accountable Care Organization (ACO), nor all Fee-for-Service.  Vermont runs a publicly operated PIHP (Prepaid Inpatient Health Plan) delivery model through its 1115 demonstration waiver.  One component of the PIHP delivery model is the ability to implement payment options available under a managed care delivery structure.  The Vermont Medicaid Next Generation ACO (VMNG ACO) payment model is a program for which a risk-bearing Accountable Care Organization (ACO) receives a prospective payment and assumes accountability for the costs and quality of care for prospectively attributed Medicaid members.  Therefore, Vermont must report encounter data for both traditional medical and Home and Community Based (HCBS) or Long-Term Services and Supports (LTSS) programs because encounter data doesn't fall into traditional reporting protocols.  

 

v  Vermont is interested in scheduling MMIS Core Solution Demonstrations. Context and expectations for those demonstrations follow below.

 

o   Vermont’s MMIS Core Claims reprocurement approach:

§  MMIS Procurement Assistance RFP:  Vermont will release an RFP for services to work with VT MMIS staff to deliver a cost-benefit analysis, roadmap, and an MMIS Claims and Fiscal Agent (FA) Services (MMIS & FA) RFP.  MMIS Procurement Assistance RFP to be released this calendar year.

§  MMIS & FA RFP:  The timing of this re-procurement is TBD. This MMIS & FA RFP will leverage NASPO with added details to address Vermont-specific needs. It's these specific needs (some identified further below) that we are interested in hearing at MESC about how vendor solutions can support them. 

o   Vermont wants to hear from MMIS solution vendors and see just how configurable your MMIS solution is for implementing Vermont-specific needs. We realize an hour can limit what can be covered but at a minimum SoV would set up time for vendors to cover the following: 

§  Your current “go-to-market” solution:

·       What's it called and when was it CMS Certified?

·       Where are you actively implementing this solution right now?

·       What is your average implementation time?

§  Show how configurable the system is for implementing any changes associated with Encounter claims for ACO or HCBS/LTSS programming (aka $0 paid claims)

§  Using the example above, show the system’s ability to receive encounter data from Medicaid enrolled and non-Medicaid enrolled providers focusing on how the system captures and displays key elements such as: 

§  Member

§  Service information – amount, duration, number delivered

§  Place of service

§  Dates of service

§  Social Determinants of Health (SDoH) data if provided.

§  Ability to use ‘shadow’ nature of the service – delivered but paid $0 because the provider is being paid differently (e.g., a bundled payment or a PMPM) but to capture a Would Have Paid amount, based on codes, so that we can track what the service would have otherwise cost, and do cost avoidance if necessary. 

§  If using claims to do this, then a way to allow these to travel down a different path than a regular Medicaid claim with all of the checks, edits and audits.

§  Ability to easily distinguish Medicaid / non-Medicaid in terms of services delivered in a program with mixed attribution – easily reported separately and together.

o   Benefit package flexibility

§  Ability to create programs with services via a configurable mechanism.

§  Ability to include / exclude benefits, services from the Medicaid Total Cost of Care

§  Ability to adjust attribution of members to programs.

§  Easier linking of members and providers to these different benefit packages and programs

§  Easy way to change rates for services with one-to-many relationships with different programs.

o   Financial module allowing for easier tracking of value-based purchasing arrangements with providers.

§  Bundles

§  PMPMs

§  Case rates, including tiers.

§  Special program payments

§  Review of Reimbursement Methodology – how flexible is your solution with regard to the procedures and adding codes to pay for new services such as housing.

o   Additional solution flexibility to address COVID-19 waiver, 1115 Waiver, and the upcoming unwind activities related to members and providers.

o   Ability to integrate with provider information, including demographics and patient population.

 

The following are additional details of other Vermont related efforts:

v  Integrated Eligibility and Enrollment (IE&E) Program:    

o   Vermont has engaged in multiple Requests for Information (RFI) to increase the collaboration and exchange of information with the vendor community. 

• Vermont’s IE&E Program Team is pursuing a “Prime” vendor to implement a "customer-focused" core system that includes a Customer Portal, Case Management, and Business Rules Engine while taking advantage – where possible – of existing technologies to meet our end-to-end customer experience needs. This effort is called the Vermont Integrated Eligibility System (VT-IES).
• The VT-IES (pronounced VEE-Ties) Project will optimize eligibility, enrollment, and benefits management functionality to allow Vermonters to apply for, receive, and manage health coverage and economic assistance benefits through a user-centric access point that is personalized, welcoming & comprehensive.

o   VT-IES is an integral component of Vermont’s IE&E System Modernization efforts and will work alongside the IE&E Noticing Project to simplify the process of applying for and managing healthcare and financial benefits for Vermonters.

o   The VT-IES Project is in the final stage of RFP development and is supported by NTT DATA. The RFP is slated for release during 4th calendar quarter of 2023.

o   For additional information on VT-IES, please visit Integrated Eligibility and Enrollment (IE&E) System | Agency of Human Services (vermont.gov)

v  Health Information Exchange (HIE) Program:

o   Has started various initiatives related to establishing Data Governance for AHS

o   Key stakeholders have met to discuss our modernization efforts and the future role HIE plays to address Social Determinants of Health (SDoH)

 

v  Systems Testing workgroup – as you may recall from last year, Vermont, with the support of NESCSO, has established this workgroup to discuss and review best practices for User Acceptance Testing, Section 508 Compliance, Testing Maturity, Testing Automation, and more.  The next System Testing workgroup meeting will be held September 21, 2023. If you are interested in joining, please sign up here.  (State and State partners only, please).   This workgroup has been working with TransformHHS (tHHS) on their workgroup page and State Health Dashboard (SHD).   If you have any questions, please contact Vermont’s Quality Testing Director, Renee Taylor, at renee.taylor@vermont.gov.

 

v  Certification workgroup – as you may recall from last year, Vermont, with the support of CMS, Shelley Dimick, Vermont’s Certification Director, has established a national Certification workgroup to support State Medicaid Agencies collaboration.  This workgroup shares best practices, lessons learned, and provides clarity related to CMS Certification policies and workflows.  Tuesday (8/22) morning, Shelley will be having an in-person S-TAG Certification meeting over breakfast at 8:30. If you are interested in joining this workgroup of if you have any questions, please contact Shelley at Shelley.Dimick@vermont.gov.

Vermont staff attending MESC include the following: 

 

 

We look forward to our interaction during MESC - safe travels and see you in Denver!